Abstract
Background
Neurology is a high-demand specialty with long waiting lines. Some pathologies require rapid decision-making. Through technology, telemedicine can allow neurological patients to ...have faster access to specialized assessment. In store-and-forward telemedicine, the specialist physician evaluates data collected by a general practitioner and optimizes screening.
Objective
The aim of the present study is to evaluate the effectiveness of asynchronous telemedicine, used to refer patients from primary care to neurology, in the city of Curitiba, in southern Brazil.
Methods
A retrospective analysis of all patients referred from primary care to neurology between September 2019 and February 2020. After a request is made by a general medical doctor for a specialist's opinion, 5 neurologists with complete access to patients' records are tasked with the decision-making. The main variables analyzed were clinical reasons for telemedicine request, neurologist decision, final diagnosis, indication for diagnostic procedures, and subsequent follow-up.
Results
Between September 2019 and February 2020, 1,035 asynchronous telemedicine consultations were performed. Headache (30.43%), epilepsy (19.03%), and dementia (15.85%) accounted for almost two-thirds of the primary care requests; one-third of the cases (33.62%) required a complementary diagnostic procedure. More than 70% of the cases did not require face-to-face assessment by a neurologist.
Conclusions
In this study, store-and-forward teleneurology successfully reduced the need for in-visit consultation in 70% of cases. Further studies should identify the best opportunities for teleneurology in the city of Curitiba to facilitate better integrated care between primary care providers and neurologists.
Abstract
Background
Stroke is one of the major causes of disability and mortality worldwide. Up to 30% of individuals who experience stroke die within 30 days, and more than 50% of those who survive ...will have some degree of disability. There are some predetermining factors based on admission data that could be used to objectively assess the odds of poor outcomes, including the Ischemic Stroke Predictive Risk Score (IScore).
Objective
To analyze and validate the IScore in patients undergoing intravenous thrombolysis for stroke and compare the results of this predictor with actual death and disability outcomes.
Methods
In a retrospective study, data were collected from a database housed at the Stroke Unit of the Teaching Hospital of Universidade Federal do Paraná, Southern Brazil. The IScore was applied to admission data from 239 patients, and the results were compared with actual outcomes (death and disability) within 30 days and 1 year after the stroke event. Data analysis was performed using an analysis of the receiver operating characteristic (ROC) curve to determine the sensitivity and specificity of the IScore in the study population.
Results
The IScore demonstrated moderate sensitivity and high specificity in patients with stroke who underwent thrombolysis when evaluated after 30 days and 1 year of the event.
Conclusions
The IScore can be applied to in stroke patients undergoing thrombolysis; therefore, it may be used as an objective prognostic tool to guide clinical decision-making. Understanding the prognosis of patients in the acute phase can assist clinicians in making the best therapeutic decisions and enable better end-of-life care.
The COVID-19 pandemic has wrought negative consequences concerning quality of care for stroke patients since its onset. Prospective population-based data about stroke care in the pandemic are ...limited. This study aims to investigate the impact of COVID-19 pandemic on stroke profile and care in Joinville, Brazil.
A prospective population-based cohort enrolled the first-ever cerebrovascular events in Joinville, Brazil, and a comparative analyzes was conducted between the first 12 months following COVID-19 restrictions (starting March 2020) and the 12 months just before. Patients with transient ischemic attack (TIA) or stroke had their profiles, incidences, subtypes, severity, access to reperfusion therapy, in-hospital stay, complementary investigation, and mortality compared.
The profiles of TIA/stroke patients in both periods were similar, with no differences in gender, age, severity, or comorbidities. There was a reduction in incidence of TIA (32.8%;
= 0.003). In both periods, intravenous thrombolysis (IV) and mechanical thrombectomy (MT) rates and intervals from door to IV/MT were similar. Patients with cardioembolic stroke and atrial fibrillation had their in-hospital stay abbreviated. The etiologic investigation was similar before and during the pandemic, but there were increases in cranial tomographies (
= 0.02), transthoracic echocardiograms (
= 0.001), chest X-rays (
< 0.001) and transcranial Doppler ultrasounds (
< 0.001). The number of cranial magnetic resonance imaging decreased in the pandemic. In-hospital mortality did not change.
The COVID-19 pandemic is associated with a reduction in TIA, without any influence on stroke profile, the quality of stroke care, in-hospital investigation or mortality. Our findings show an effective response by the local stroke care system and offer convincing evidence that interdisciplinary efforts are the ideal approach to avoiding the COVID-19 pandemic's negative effects, even with scarce resources.
Abstract
Background:
Patent foramen ovale (PFO) has been considered a potential mechanism of embolic stroke of undetermined origin.
Objective:
The aim of the present study was to identify the ...features of the right-to-left shunt (RLS) in patients with undetermined embolic ischemic stroke and compare them with those of patients with non-cardioembolic ischemic stroke.
Methods:
A retrospective study was conducted with 168 patients with stroke and RLS separated into the following two groups: the undetermined embolic stroke group (UES group) and non-cardioembolic stroke group (NCES group). All patients were assessed by transcranial Doppler to evaluate the presence and quantification of microembolic signals (MES) at rest and under Valsalva maneuver.
Results:
Of all patients evaluated in the current study, 96 were included in the UES group and 72 in the NCES group. In the UES group, 65 patients had RLS with ≥10 MES (67.7%), which was higher than that observed in the NCES group (51.4%, p=0.038). According to the moment of the cardiac cycle, 75 patients (78.1%) in the UES group had a positive test at rest compared to 42 (58.3%) in the NCES group (p=0.007).
Conclusions:
The current study demonstrated that almost 70% of patients with undetermined embolic stroke and PFO presented a large RLS and more than 75% had RLS at rest. These findings suggest that the size of the shunt should be taken into account when evaluating whether PFO could be a possible mechanism underlying cryptogenic stroke.
The rapid evaluation of non-contrast-enhanced computed tomography (NCCT) brain scans in patients with anterior stroke symptoms saves time and favors optimal and prompt treatment. e-ASPECTS is a tool ...that automatically calculates the Alberta Stroke Program Early CT Score (ASPECTS) values, leading to a more accurate and timely image evaluation.
To determine the ability of e-ASPECTS in differentiating images with and without injury.
One-hundred sixteen patients admitted to a stroke unit in a Brazilian tertiary hospital underwent a CT scan at admission and at least one control brain imaging (NCCT or magnetic resonance imaging - MRI) 24 hours after admission. ASPECTS evaluation was performed by three neuroradiologists, three neurologists, and three neurology residents, all blinded to the symptoms and the injury side. The scores were compared to the ground truth, and an ASPECTS score was provided by two independent non blinded evaluators. Sensitivity and specificity were analyzed, and receiver operating characteristic curves, Bland-Altman plots with mean error score, and Matthews correlation coefficients (MCCs) were obtained for ASPECTS scores, assuming values equal to 10 for images without injury and values other than 10 for images with ischemic injury.
e-ASPECTS demonstrated similar performance to that of neuroradiologists and neurologists, with an area under the curve of 0.78 and an MCC value of 0.48 in the dichotomous analysis. The sensitivity and specificity of e-ASPECTS were 75% and 73%, respectively.
e-ASPECTS is a validated and reliable tool for determining early signs of ischemia in NCCT.
The role of patent foramen ovale is a field of debate and current publications have increasing controversies about the patients' management in young undetermined stroke. Work up with echocardiography ...and transcranial Doppler (TCD) can aid the decision with better anatomical and functional characterization of right-to-left shunt (RLS). Medical and interventional strategy may benefit from this information.
a group of experts from the Latin American participants of the Neurosonology Research Group (NSRG) of World Federation of Neurology created a task force to review literature and describe the better methodology of contrast TCD (c-TCD). All signatories of the present consensus statement have published at least one study on TCD as an author or co-author in an indexed journal. Two meetings were held while the consensus statement was being drafted, during which controversial issues were discussed and voted on by the statement signatories. The statement paper was reviewed and approved by the Executive Committee of the NSRG of the World Federation of Neurology. The main objective of this consensus statement is to establish a standardization of the c-TCD technique and its interpretation, in order to improve the informative quality of the method, resulting in expanding the application of TCD in the clinical setting. These recommendations optimize the comparison of different diagnostic methods and encourage the use of c-TCD for RLS screening and complementary diagnosis in multicenter studies.
Background: Dual antiplatelet therapy (DAT) is a therapeutic option for patients with minor ischemic stroke (IS) or transient ischemic attack (TIA). No study has evaluated the incidence of early ...bleeding in patients with moderate to major ischemic stroke. The current study aimed to analyze both the frequency of early bleeding and hospital morbidity related to DAT for either acute IS or TIA regardless of admission National Institute of Health Stroke Scale (NIHSS) score. Methods: This was a retrospective analysis based on data collected from a prospective data bank of a single center. We included patients who underwent DAT in the first 24 hours of symptom onset with a loading dose (aspirin 300 mg + clopidogrel 300 mg) on the first day, followed by a maintenance dose (aspirin 100 mg + clopidogrel 75 mg). We analyzed intracranial and/or extracranial hemorrhage that had occurred during the hospital admission, symptomatic bleeding, modified Rankin Scale (mRS) score at discharge, and death rates as outcomes. Results: Of the 119 patients analyzed, 94 (79 %) had IS and 25 (21 %) had TIA. Hemorrhage occurred in 11 (9.2 %) and four (3.4 %) patients with TIA or NIHSS ≤ 3, respectively, although none were symptomatic. Patients with bleeding as a complication had higher admission NIHSS 4 (3–7) vs. 2 (1–4), p = 0.044 and had higher mRS at discharge (mRS 2 1–5 vs. mRS 1 0–2, p = 0.008). These findings did not indicate increased mortality, as one (9 %) patient died from bleeding and two (1.8 %) patients died without bleeding (p = 0.254). Conclusion: DAT seems to be a safe therapy in patients regardless of admission NIHSS if started within the first 24 h after symptom onset because only 1.6 % of patients had symptomatic bleeding.
Precise evaluation of brain computerized tomography (CT) is a crucial step in acute ischemic stroke evaluation. Electronic Alberta Stroke Program Early CT Score (E-ASPECTS) helps in the selection of ...patients who may be eligible for thrombolysis. This paper seeks to assess the performance of emergency physicians (EPs) in the evaluation of ASPECTS scores with and without the use of E-ASPECTS and to compare their results with neuroradiologists.
A total of 116 patients were selected. Initially, two EPs and two neuroradiologists evaluated the admission nonenhanced CT without E-ASPECTS. Then, after 30 days, they re-evaluated the images using E-ASPECTS. Sensitivity, specificity, Matthew's correlation coefficients (MCC), and receiver operating characteristic curves were generated for analysis before and after the software use.
Eps' performances improved when they used E-ASPECTS, with their results closer to those obtained by neuroradiologists. In the initial evaluation, MCC values for the two EPs were -0.01 and 0.04, respectively. After the software assistance, they obtained 0.38 and 0.43, respectively, which was closer to the scores obtained by the neuroradiologists (0.53 and 0.39, respectively).
This is the first study that has specifically compared neuroradiologists' and EPs' performances before and after using E-ASPECTS. E-ASPECTS assisted and improved the evaluation of the images of patients with acute ischemic stroke.
Artificial intelligence in the emergency room may increase the number of patients treated with tissue-type plasminogen activators.
Large population campaigns have been conducted in Brazil to improve knowledge about the signs and symptoms of stroke and the importance of time to care. Parallel to these important actions, we aimed ...to evaluate the lay knowledge of patients with atrial fibrillation, a well-recognized etiology of stroke, adequate treatment and management of which can prevent up to 30% of cerebrovascular events.
We questioned 143 patients with atrial fibrillation about the risks associated with the disease.
Ninety-one percent were on anticoagulation treatment. Of the total, 63.6% reported having been informed about the risks and benefits of anticoagulants but only 46.9% were able to correctly mention one of these risks. Ischemic stroke was identified as a risk by only 25.9% and hemorrhagic stroke was not mentioned. A CHADS2 ≥ 2 was scored by 84.0% of the patients.
Our study showed an alarming knowledge gap in patients with atrial fibrillation. Difficulty in adherence to treatment resulting from the failure of this communication is possibly one of the factors responsible for the high incidence and recurrence of stroke, and should not go unnoticed.
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